The politics of service delivery

Teachers in Tanzania are absent 23 percent of the time; doctors in Senegal spend an average of 39 minutes a day seeing patients; in Chad, 99 percent of non-wage public spending in health disappears before reaching the clinics.

But why do these failures persist? Because they represent a political equilibrium where politicians and service providers (teachers, doctors, bureaucrats) benefit from the status quo and will therefore resist attempts at improving services. For instance, teachers are often the campaign managers for local politicians. They work to get the politician elected, in return for which they get a job from which they can be absent. Powerful medical unions ensure that their members can work in the private sector and neglect their salaried government jobs. The losers are the poor, whose children don't learn to read and write, or get sick and die because the public clinic is empty.

The plenary session of the AERC's biannual workshop, on Institutions and Service Delivery, corroborated this political equilibrium and suggested some ways of disrupting it. Tessa Bold and Jakob Svensson's paper described a randomized control trial where a program of contract teachers in Kenya was implemented by both NGOs and government. The improvement in learning outcomes was only in schools where the program was introduced by NGOs. When the government ran the program, there was no discernible improvement--probably linked to the strong protest from the (permanent) teachers unions.

In another experiment, they provided teachers with more resources, but subjected some to monitoring by the local community. Only when the additional resources were accompanied by community monitoring was there a significant improvement in student learning.

These and other examples illustrate a fundamental point. We can think of several "gimmicks" to make service providers accountable, but unless the underlying politics is conducive to those innovations, they are unlikely to work.

A bonus to doctors for performance seems to improve health outcomes in Rwanda, but a program to introduce time-stamp machines to monitor health workers' presence in another country failed: the night before the program was to start all the machines were vandalized.

How can we disrupt this equilibrium to improve services for poor people? One possibility is to provide them with information. We saw that community monitoring (poor people obtaining the information directly) had an effect on teacher performance. But more broadly, poor people do vote. If, with information, they vote along service delivery lines--rather than for politicians from their own ethnic or religious group, or who promise them private goods such as a job building roads--then it would be more difficult for politicians to ignore service delivery failures.

You might ask why we need to inform poor people. Don't they already know that the teacher or doctor is absent? Life is so difficult when you're poor that you may not associate absentee doctors or ill-equipped classrooms with public policy failures. As part of a village immersion program, I spent time with a poor woman in Gujarat, India. One day, her kid was sick. She took him to a private doctor whose qualifications were suspect. When I asked her why she didn't take him to the free, public clinic, she said (rolling her eyes), "because the doctor's not there." I then asked her why she thought the doctor wasn't in. "Because the rains didn't come," she replied.

If we want to inform poor people so they can vote for programs in their own interest, how do we do so? We know very little about what types of information campaigns work (link to my blog post about critiques of information campaigns). This is an area that is ripe for randomized control trials, such as this one in Benin.

Information may not be the only solution. The underlying problem is that politicians are behaving "clientelistically"--more interested in handing out private goods to their "clients" rather than public goods that benefit society, especially the poor--and getting away with it (they get elected). And if most politicians behave this way, it's in every politician's interest to follow suit. How can we move from clientelism being the norm to one where it is the exception?

Comments

Shanta,
Further exacerbating the problem is that any voting the poor and underserved might do could come back to haunt them if the powers that be have access to the information. This can skew the objective results if not taken into account.

Shanta, thanks for this. In DFID India, in the late 90's, we started to do research of voting behavior in rural western Orissa, with the aim to better understand why voters from poor communities / tribes / etc would continue to vote for politicians with questionable performance and reputation (i.e. why do poor people keep on voting for politicians who do not govern in their favor?).
Essentially, the research indicated that there are ways in which ruling political groups manipulate and control communication channels, especially in areas with low literacy rates. For example: in many villages the shopkeeper was the key source of information about the government in Bubaneshwar, being one of few who could read and practically the only one who would regularly receive newspapers together with the delivery of goods for the shop. The study showed that in many remote village in Western Orissa the voting behavior of the villagers reflected the political preferences of the village shop keeper. It is likely that other groups with better access to information (teachers, doctors, etc) play a similar role in mobilising voters and influencing voter behavior.

I am so tired of the development partners doing half-assed (pardon my slang) programs and projects and then turn around and complain about the corrupt people that disrupt services to the poor. Guess what, the programs are designed to fail and there is no if's and's and whatnot about it. Take an example of all the literacy programs in all the schools in Africa. You find all these programs in schools but no support services like libraries or community centers to educate the parents. The nearest library multitudes of primary and secondary schools in my village is probably 60 miles away. Why don't those so called experts who design the literacy programs build in libraries and; actually the local people would build them with their own hands.
Also, Yes, information is one of the solutions but you have to empower the community leaders who are not part of the establishment. In any community, you will find retired teachers, bureaucrats, etc who could do extra work in the communities, but there is nothing to do. If there were community centers with programs that educate and empower the locals, this human capital would not be wasted. Most of them, all they need is recognition.
Find the right people in the community who are; to quote Malcolm Gladwell, "connectors". In any community, these people are people of integrity and will provide the oversight needed to bring the rest of the leaders on board. And believe it or not, young people are more attuned to community development they get credit for. And that's how you deliver services to the people.

Sometimes --perhaps for our own purposes-- we take a simple problem and make it a complex one. There is a reason why there is correlation between developed countries and democracy-----true democracy. Most developing countries are going through the same stages that developed countries went through during their infancy. Sure, it would be nice if developing countries avoided the mistakes of the developed ones and thus leapfrogged those stages. But we know that is not going to happen. Rulers prefer absolute control. This is true even in developed countries but thankfully, there, it is mitigated by (i) division of powers, (ii) meaningful controls, (iii) applicable laws and (iv) accountability. Show me a developing country and I will show you a country that is missing these four aforementioned pillars necessary for advancement. Clearly, there is a movement toward real democracy in many of the developing countries but it is still far off. Most of these governments still control the final outcome and consequently do not fear the ballot. in brief, as long as politicians are certain that they will remain indefinitely in office because of the four missing pillars, the poor will remain victims to their whims. This clearly has a cascading effect downwards. In business schools, we are taught that the leadership sets the tone of the organization. This applies to countries as well. Teachers, doctors and other service providers understand it very well. We do not need studies to know this. If donors and aid givers were really serious about development, they would limit their aid and loans to the four pillars. Somehow, they have consistently looked only at the symptoms instead of the root causes of the problem. It is almost impossible to have development without accountability.
Thanks.

Shanta -- Thanks for a very interesting post. I'm fairly sold by your core thesis here, that in order to fix service delivery failures in Tanzania or Kenya, we need to fix the underlying political equilibrium.
But I think this is harder than the second half of your post suggests. I fear the interventions required to 'fix' the political equilibrium are gonna be much deeper and look a lot more heavy-handed than an information campaign. Is the Bank ready to go there?
Take the Kenya education example. You mentioned, via Tessa & Jakob's reference, our Kenya contract teacher RCT where side-by-side implementation of the 'same' intervention by an NGO and the Ministry of Education produced dramatically different results. (Thanks for the plug by the way -- a full draft of the RCT paper is now available here http://www.cgdev.org/doc/kenya_rct_webdraft.pdf)
What would it take to fix the government failures that produced this disparity?
We actually found no effect from training parents on the School Management Committee about their roles and responsibilities in holding teachers to account. Similarly, we experimented with devolving control of contract teachers to local school committees. Again, these tweaks to improve parental involvement had no effect on test scores overall, and didn't significantly reduce the NGO-government disparity.
(This echoes work in India by your colleague Stuti Khemani and co-authors who find no impact of information or encouraging community involvement in schools on test performance. http://www.nber.org/papers/w14311 )
Government scale-up of the NGO contract teacher model in Kenya failed on two fronts: potentially weak oversight by the middle tiers of Ministry bureaucracy, and insufficient political will in the face of organized resistance by teachers' unions at the national level. That tends to make me think we should be experimenting and intervening higher up the bureaucratic food chain, rather than relying on information dissemination at the grassroots level.
Right now, it's not clear that there is an effective way for even well-informed parents to dramatically improve their public schools if they tried.

This is interesting issue, always it was on my mind, the most thieves and ones who makes our third world countries (poor countries) to lag behind are service deliverers (Teachers, Doctors, Nurses, Lectures, Accountants, Lawyers etc). In our government there is no mechanism for monitoring and measuring service deliverers performance, always they demand wages and salary incremental based on inflation and changes on living conditions, but they don’t reflect on comparison to what they deliver. Service deliverers on first appointments always they bargain salaries based on sector salary and labour supply and demand history. When looking in government budgets and strategies, there is no any effort to make sure adjustments and focuses are made to make sure employed staffs are delivering at required rates, this can reduce recurrent expenditures.
Let’s take an example of 5 teachers at rate of 23% absentees’ it means that one extra teacher is working to compensate the time of 5. According to year 2010 the number of primary school teacher in Tanzania was 165,856 (World Bank, 2011). If we make calculation if they are working 100% the country needs only 127,709 teachers to meet the same current achievements. That means the government employ 38,147 teachers to covers laziness and absenteeism. Putting in monetary value if current salary 135,000 (based on minimum wages) government make loss of Tshs 5,149,845,000 (five Billion) per month, for one accounting years comes to 61.7 billion. This data is only for primary school teacher and differences in salary scales are not taking in consideration.
This is our country lets be serious to make changes, together we build our nation.

I enjoyed reading this article. In Kenya the teachers union are known only for agitating for increased pay and less for demanding quality from thier members. Service delivery is very low even with introdution of performance contract in the public service.

I am associated with a large scale state level reform effort in healthcare delivery through the government. The question in front of us is very much the one being debated in this blog post -- is there a sustainable way to get the community engaged when they deal with their service provider? Would, for example, putting up a placard outside each Primary Health Centre which clearly lists what people have a right to expect have an impact?

Nachiket, thanks for your question. I think we need to do more than just list what people have a right to expect, although that's important. The issue is what kinds of information will prompt service providers to deliver better services? As the Bjorklund and Svensson work shows, posting information on the quality of the clinic relative to other clinics seems to have some effect. Letting people inform some central authority whether or not the doctor is in the clinic, possibly by using their cell phone, can also help. Finally, informing people not just about their rights, but also about redress mechanisms (to whom to complain, etc) has been shown to have some effects, as Billy Jack's and James Habyarimana's work on matatu drivers in Nairobi shows. Best regards and it's nice to be in touch with you again. Shanta

Thank you for your response. Clearly ideas for us to examine and work on. I also had the opportunity to meet up with Ms.Nayana Chowdhury (http://in.linkedin.com/pub/nayana-chowdhury/15/6b5/26a) of the Sir Dorabji Tata Trust (http://www.dorabjitatatrust.org/id/102/Civil%20Society%20Program/) and was quite impressed with their Empowering Rural Women (ERW) programme. I like to think of her work as "non-confrontational activism". It seems to have some of the elements that you point out and has produced some very impressive results. I am hoping to take her guidance in the work that I am involved with in the healthcare sector.